卵圓孔未閉封堵術(shù)：爭(zhēng)論與發(fā)展（中英文）課件

1、卵圓孔未閉封堵術(shù)：爭(zhēng)論與發(fā)展May 9, 2009Andrew D. Michaels, MD, MAS, FACC, FAHADirector, Cardiac Catheterization Laboratory and Interventional CardiologyUniversity of Utah, Salt Lake City, Utah胎兒循環(huán)胎兒期，氧合血液由臍靜脈經(jīng)下腔靜脈進(jìn)入右房血流由下腔靜脈經(jīng)過(guò)Eustachian 瓣流到卵圓窩.出生后房間隔發(fā)育宮內(nèi)出生后Hagen, Scholz. Mayo Clin Proc 1984; 59: 17-20.人口的75 人口 的2

2、5% PFO相關(guān)臨床綜合癥體位相關(guān)呼吸困難 Platypnea orthodeoxia減壓病/高原性肺水腫腦血管事件/TIA偏頭痛Platypnoea Orthodeoxia罕見直立體位引起的呼吸困難，伴有低氧血癥機(jī)制：右向左房間分流Aigner et al. Eur J Cardiothor Surg 2008; 33: 268.Medina et al. Circulation 2001; 104: 741.隱匿性腦卒中40歲男性，突發(fā)失語(yǔ)既往史無(wú)特殊. 無(wú)明顯腦卒中病因.TEE: 發(fā)現(xiàn)房間隔瘤與 PFO.常見伴發(fā)癥:50% 隱匿性腦卒中患者有 PFO.推測(cè)機(jī)制:靜脈血栓反常性體循環(huán)栓塞癥

3、.PFO 通道內(nèi)原位血栓形成造成栓塞血栓流經(jīng) PFO首例 PFO伴血栓形成報(bào)道于1876.既往通過(guò)超聲心動(dòng)圖及術(shù)中見到嵌頓于PFO的血栓.但無(wú)法觀察到小栓子的流程。服用阿司匹林的PFO患者腦血管事件/TIA復(fù)發(fā)率較高M(jìn)as et al. NEJM 2001; 345: 1740-6.581 名患者有隱匿性腦卒中均接受阿司匹林治療PFO 封堵器PFOASDAmplatzer PFOSTARFlexAmplatzer ASOCardioSEALHelexAmplatzerCribiform ASD左房傘植入右房傘植入植入前植入后偏頭痛與PFO的關(guān)系12人口患有偏頭痛 (女性18% ; 男性6% )

4、偏頭痛患者中 存在PFO的占：48%的偏頭痛伴視覺(jué)先兆 123%的偏頭痛不伴視覺(jué)先兆20% 正常人隱匿性腦卒中伴PFO患者中偏頭痛發(fā)生率52% 有偏頭痛伴視覺(jué)先兆271% 封堵術(shù)后癥狀緩解3偏頭痛患者較正常人MRI檢查病變陽(yáng)性率高13倍4Anzola. Neurology 1999;52:1622-5.Sztajzel. CV Diseases 2002;13:102-6.Wilmshurst. Lancet 2000;356:1648-51.Kruit. JAMA 2004;294:427-34.卵圓孔未閉與偏頭痛之間可能的病理生理相關(guān)性經(jīng)過(guò)PFO的微小栓子可引起偏頭痛.體液因子（如5HT)

5、 免受肺降解,引起偏頭痛.MIST研究結(jié)果Dowson A, et al. Circulation 2008; 117: 1397-404.無(wú)偏頭痛發(fā)作患者, n03131.0偏頭痛發(fā)作頻率/月, meanSD4.822.443.231.804.512.173.532.130.14MIDAS總評(píng)分, median (range)36 (3108)17 (0270)34 (2189)18 (0240)0.88頭痛天數(shù)/3月 (MIDAS), median (range)27 (070)18 (090)30 (580)21 (080)0.79HIT-6總評(píng)分, meanSD67.24.759.59

6、.366.25.158.58.60.77術(shù)前術(shù)前術(shù)后術(shù)后P value手術(shù)組 (n=74)假手術(shù)組(n=73)偏頭痛隨機(jī)臨床試驗(yàn)NMT Medical closed MIST II (January 24, 2008).PREMIUM (AGA Medical) 及 ESCAPE (St Jude Medical) 仍在進(jìn)行中.PFO 封堵器技術(shù)現(xiàn)況與展望目前封堵器技術(shù)的局限性大型，永久性植入物.遠(yuǎn)期并發(fā)癥：心率失常，炎癥，糜爛，血栓形成，過(guò)敏反應(yīng). 未來(lái)的封堵器技術(shù)小型封堵器.生物可吸收(BioSTAR).可縫合封堵器.射頻消融.Mullen et al. Circulation 2006;

7、 114: 1962-7.結(jié)論目前隱匿性腦卒中的藥物治療療效欠佳.研究提示存在高危復(fù)發(fā)腦卒中的亞組.尚無(wú)隨機(jī)臨床試驗(yàn)支持任何藥物治療經(jīng)皮 PFO封堵術(shù)可能成為隱匿性腦卒中預(yù)防的主要干預(yù)手段.安全.非隨機(jī)臨床試驗(yàn)資料提示對(duì)可有效預(yù)防腦卒中.有待關(guān)于腦卒中與偏頭痛的進(jìn)一步臨床研究結(jié)果.結(jié)論P(yáng)atent Foramen Ovale Closure:Controversies and Accomplishments May 9, 2009Andrew D. Michaels, MD, MAS, FACC, FAHADirector, Cardiac Catheterization Laboratory

8、 and Interventional CardiologyUniversity of Utah, Salt Lake City, UtahFetal CirculationDuring fetal life, oxygenated bloodreturning from the umbilical veinenters the RA through the IVC.Blood flow is directed by theEustachian valve from the IVCto the fossa ovalis and through the PFO.Post-Natal Septal

9、 DevelopmentIn UteroAfter BirthHagen, Scholz. Mayo Clin Proc 1984; 59: 17-20.75% of Population 25% of PopulationClinical Syndromes Associated with PFOPlatypnea orthodeoxiaDecompression sickness/high-altitude pulmonary edemaCVA/TIAMigrainePlatypnoea OrthodeoxiaUncommon syndromeDyspnea induced by upri

10、ght posture, with associated hypoxemiaMechanism: right-to-left interatrial shuntingAigner et al. Eur J Cardiothor Surg 2008; 33: 268.Medina et al. Circulation 2001; 104: 741.Platypnea Orthodeoxia100 cases in literature since 1949PFO associated with:Aortic aneurysmChest deformityPost-pneumonectomy50

11、have undergone device closureDecompression Sickness230 asymptomatic divers surveyed27% had a PFODecompression chamber required:19% with a PFO2% without a PFOTorti et al. Eur Heart J 2004; 25: 1014-20.Cryptogenic Stroke Case40 yo man with sudden aphasia.No medical history. No obvious cause of stroke.

12、TEE: atrial septal aneurysm and PFO.Associations:50% of people with cryptogenic stroke have a PFO.Presumed mechanism:Paradoxical embolism of venous thrombus.In-situ thrombosis within PFO tunnel with embolization.Thrombus in transit through PFOFirst case of PFO with thrombus described in 1876.Thrombu

13、s caught in PFO has been seen by echo and at surgery.However, passages of small emboli are impossible to prove.Higher CVA/TIA Recurrence Rate in Patients with PFO + ASAMas et al. NEJM 2001; 345: 1740-6.581 patients with cryptogenic strokeAll treated with aspirinWarfarin-Aspirin Recurrent Stroke Stud

14、yMohr et al. NEJM 2001; 345: 1444-51.N=2206 with ischemic CVA (56% lacunar; 25% cryptogenic; 13% large vessel)Randomized to ASA 325mg vs WarfarinConclusion: Antiplatelet and anticoagulant therapy equally (in)effectiveMedical Therapy vs. PFO ClosureWindecker et al. JACC 2004; 44: 750-8.N=308 with cry

15、ptogenic CVA and PFORandomized to medical therapy or PFO closureMedical Therapy vs. PFO Closure:Meta-Analysis of Observational StudiesKhairy et al. Ann Int Med 2003; 139: 753-60.Medical Therapy (6 studies)N=8953.8 - 12.0%4.9PFO Closure (10 studies)N=13550 - 4.9%3.0Recurrent CVA/TIA1-YearDeath/CVA/TI

16、AEvents/100 pt yrsPFO DevicesPFOASDAmplatzer PFOSTARFlexAmplatzer ASOCardioSEALHelexAmplatzerCribiform ASDLeft Atrial Disc DeploymentRight Atrial Disc DeploymentPrePostAssociation Between Migraine and PFOMigraine headache affects 12% of population (18% F; 6% M)Incidence of PFO in patients with migra

17、ine48% if migraine with aura123% if migraine without aura20% in controlsIncidence of migraine in cryptogenic stroke with PFO52% had migraine with aura271% had suppression post-closure3Migraine patients have 13 times higher incidence of MRI lesions4Anzola. Neurology 1999;52:1622-5.Sztajzel. CV Diseas

18、es 2002;13:102-6.Wilmshurst. Lancet 2000;356:1648-51.Kruit. JAMA 2004;294:427-34.Potential Pathophysiologic Association Between PFO and MigraineMicroembolism through PFO triggers migraine.Humoral factors (i.e., serotonin) escape pulmonary degradation, triggering migraine.Published MIST ResultsDowson

19、 A, et al. Circulation 2008; 117: 1397-404.Patients with no migraine attacks, n03131.0Frequency of migraine attacks/mo, meanSD4.822.443.231.804.512.173.532.130.14Total MIDAS score, median (range)36 (3108)17 (0270)34 (2189)18 (0240)0.88Headache d/3 mo (MIDAS), median (range)27 (070)18 (090)30 (580)21

20、 (080)0.79HIT-6 total score, meanSD67.24.759.59.366.25.158.58.60.77BaselineBaselinePostPostP valueImplant (n=74)Sham (n=73)Migraine Randomized Clinical TrialsNMT Medical closed MIST II (January 24, 2008).PREMIUM (AGA Medical) and ESCAPE (St Jude Medical) still enrolling.Current and Future PFO Device TechnologiesLimitations of Current Device